Please Read and Fill Out ALL Details Incomplete Forms Will Not Be Processed

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1 Portland Dune Buggy Club Inc. PO BOX 463 Portland Mobile: Member No. Received / / Processed / / Reg No A3587S Please Read and Fill Out ALL Details Incomplete Forms Will Not Be Processed NAME Mr. / Miss / Ms / Mrs... ADDRESS... CITY / TOWN / SUBURB.....POSTCODE... DOB / / PHONE Home Work Mobile FAMILY MEMBERS Mr /Miss/Ms/Mrs Ambulance Member Yes No (Please Circle) Child 1 Child 2 Child 3 Date of Birth / / Date of Birth / / Date of Birth / / (Children 12 to 21 years old inclusive are covered by Family Membership) MEMBERSHIP TYPE Single Membership $ Expires 30 th June annually Note: This allows camping without charges from P.V. Family Membership $ Expires 30 th June annually Note:This allows camping without charges from P.V. Please make cheques or money orders payable to: Portland Dune Buggy Club Inc. PDBC EFT Banking Details listed below: BSB (Bendigo Bank Heywood) Acc Number Acc Name Portland Dune Buggy Club Inc. General Account Note: Please put your name in the Description Box Please remember if you pay by EFT you still must post, fax or your completed forms otherwise your membership will not be processed

2 MEMBERS STATEMENT I / We the undersigned agree to abide by the Constitution, Bylaws and Rules of the Portland Dune Buggy Club Inc. and the Regulations of Parks Victoria. I/We acknowledge and agree as a condition of Membership that neither Portland Dune Buggy Club Inc, nor Parks Victoria, nor the land owners or lessees, or their respective servants, officials, representatives or agents, shall be under any liability for my/our death or any bodily injury, loss or damage which may be sustained or incurred by me/us, as a result of participation in or being present at any events, except in regard to any rights I may have arising under the Trades Practices Act I/We acknowledge that operating a motor vehicle may be dangerous and accidents causing death, bodily injury, disability and property damage can happen. PLEASE SIGN BELOW Member... Date... Member... Date... (Two signatures for Family membership) Parent / Guardian Consent CONSENT (If a member is under 18 years of age, this form must be counter signed by the appropriate parent or guardian) I, being the parent / guardian of (Insert Name/s), have read the whole of this document and consent to him / her participating. In doing so, I acknowledge that operating a motor vehicle may be dangerous, and agree that neither Portland Dune Buggy Club Inc, nor Parks Victoria, nor the Organisers shall be under liability whatsoever for any death or bodily injury, loss or damage which may be sustained by.. Or by me, howsoever such death or bodily injury, loss or damage is caused by negligence or otherwise. Signed.Parent / Guardian* Date *Delete whichever does not apply. If all forms are not fully completed and signed and the correct fees forwarded membership cannot be issued

3 PORTLAND DUNE BUGGY CLUB Inc Reg No A3587S VEHICLE REGISTRATION FORM Name Address Buggy 1 Chassis No OFFICE USE ONLY Payment Type 2 Chassis No Oddessy 1 Chassis No 2 Chassis No Cheque Cash Direct Deposit Date Received No. / / 4x4 Sticker/s and Card Posted: Date Posted: / / Y / N 1 Road Rego 2 Road Rego The Secretary will issue club Membership Card and Sticker for you Vehicle, Please fix this to your vehicle so it can be viewed at a distance. A Chassis Number and NRV Insurance is required for vehicles that are not Road Registered. All Vehicles that are not Road Registered must have a Chassis Number and this number must be stamped into the chassis in an easily viewed position. The Secretary will issue Chassis Numbers with accepted membership applications. Chassis Numbers will stay with the vehicle. Have a nice day

4 PDBC CHECKLIST FOR ALL MEMBERS WITH NON-REGISTERED VEHICLES MUST FILL OUT AND SIGN THIS FORM BEFORE YOU MAY DRIVE YOUR VEHICLE AT SWAN LAKE SAND DUNES. REQUIREMENT Please Tick Battery Isolator Suitable Battery Cover or battery is in battery box e.g. to contain Acid spill or leakage Helmets in good condition & fit occupants correctly Window nets or arm/wrist restraints Seat belts in good condition i.e. Not frayed, modified or re-stitched in any way Seats in good condition Note: If a car seat is fitted they must have a horizontal bar running directly behind seats at shoulder hight Brake light to operate with Brake pedal operation Head Rest or High Back Seats Horn or similar warning alert At least one rear view mirror Fire extinguisher in working order Flag is minimum 4 metres from the ground Roll hoops conform to club rules E.g. Tube must be at least 38mm outside dia. with 2.4mm wall. Main/rear roll hoop must have at least one diagonal cross brace. No joins, extensions or welded elbows in main roll hoops Cockpit free from sharp and protruding objects Effective fire wall between fuel tank and occupants Fuel tank vent that will prevent fuel leaking in the instance of roll over Throttle return spring Brakes in working order Chassis No Hub nuts, ball joints & wheel bearings fitted with lock tabs or split pins I agree to comply with the regulations as defined by the Portland Dune Buggy Club Incorporated (PDBC) and declare that my Off-Road Vehicle fully complies with the regulations as defined by the PDBC... Name... Signed... Date...

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